An inadequate donor left atrial cuff is a rare technical issue after graft procurement for lung transplantation. Our case demonstrates that reconstruction of an inadequate cuff by biological patch repair is feasible in such cases. Various degrees of left atrial cuff insufficiency and reconstruction techniques have previously been described by Oto et al. in 2006 [
2]. In our case, the lower pulmonary vein was circumferentially amputated. A cone-shaped neoatrial cuff was created by suturing a centrally cut out biological patch to the orifice, thereby successfully avoiding a right lower lobectomy. While biological grafts are commonly used in the field of cardiovascular surgery, their application in lung transplantation has rarely been reported [
2]. As an alternative, donor pulmonary artery remnant or a donor pericardial patch can be used to create additional length and diameter of the venous cuff, [
2]. In our case however, the defect was too large to be reconstructed by the remnant donor pulmonary artery. Nevertheless, it can be valuable to retain residual donor pericardium, pulmonary artery or parts of the superior vena cava during the back table preparation in case of a reconstruction. Further options to overcome the challenge of an insufficient cuff include the use of the donor pericardium surrounding the pulmonary venous confluence as a “pericardial skirt” [
3,
6] or on the left side, a direct implantation into the left atrial appendage [
7]. After reconstruction, signs of congestion should be closely monitored. Intraoperatively, the implanted lung should be assessed for darker discoloration or increasing consolidation. A constrained oxygenation or rising pulmonary arterial pressure can be suggestive for a venous obstruction and should be investigated by transesophageal echocardiography to distinguish reduced pulmonary venous flow from signs of cardiac failure or fluid overload [
2]. Postoperatively, a contrast-enhanced CT or V/Q-scan can confirm an open anastomosis. Due to the transient renal insufficiency, a V/Q scan was preferred to verify the patency of the right inferior pulmonary vein in our case. Considering the high flow rate at the atrial anastomosis and since bovine pericardial repair does not require permanent anticoagulation, sub-therapeutic anticoagulation was administered for 6 weeks.
In order to avoid potential technical errors during graft procurement, a standardized protocol for donor lung procurement should be followed. A recently published consensus statement by the International Society for Heart and Lung Transplantation (ISHLT) addresses the standardization in the procurement process and particularly the surgical technique [
4]. The consensus statement furthermore emphasizes the importance of an early evaluation of the organ and prompt communication of the findings to the transplant center [
4].
Considering the shortage of suitable donor organs for lung transplantation, it is important to consider every donor organ for transplantation, even when facing technical difficulties. This case exemplifies a way of overcoming the challenge of an insufficient left atrial cuff by reconstruction with an acellular biological patch. The technique allows the formation of a neo-atrial cuff which can then be safely anastomosed to the recipient left atrium. Postoperative assessment by V/Q scan confirmed an unrestricted patency of the venous drainage in the affected lobe. On a second note, this case emphasizes the importance of careful inspection and evaluation of the donor lung immediately after procurement and early communication with the recipient implant team.